trauma Flashcards

Question

facial trauma: orbital fx: definition and sx | - [ ] Orbital floor blow out: findings, diagnostic testing, management

Answer 1

Orbital fracture: Fracture involving the bones of the orbit, commonly due to blunt trauma. Blowout fracture: Fracture of the orbital floor or wall without involvement of the orbital rim. -blunt or penetrating trauma sx: - -orbital pain with eye movement -floor- diplopia! and/or nausea -roof- forehead numbness -proptosis or enophthalmos -widened intercanthal distance -bradycarida!- oculocardiac reflex causes dec HR when pressure apple to extraocular muscles -numb on middle face (maxillary branch of trigeminal runs thru inferior orbital groove) -may entrap !inferior rectus muscle! -> !vertical stabismus! (one eye deviated up) ## Footnote 🦴 Orbital Fracture Overview 🧱 Definition Orbital fracture: Any break in the bones forming the eye socket (orbital roof, floor, medial or lateral wall) Blowout fracture: Fracture of the orbital floor or medial wall without involvement of the orbital rim Usually from blunt trauma (e.g. punch, baseball, MVC airbag) ⚠️ Key Symptoms / Exam Findings Finding Cause / Clue Orbital pain with eye movement Muscle entrapment or periorbital edema Diplopia (especially vertical) Entrapment of inferior rectus muscle (can't look up) Enophthalmos Sunken globe — suggests floor blowout Proptosis Retrobulbar hematoma or swelling Hypoesthesia of midface Infraorbital nerve injury (V2, maxillary branch of CN V) Bradycardia Oculocardiac reflex (triggered by pressure on eye muscles) Widened intercanthal distance Suggests nasoorbitoethmoid (NOE) fracture Forehead numbness Injury to supraorbital nerve → orbital roof fracture 🧪 Diagnosis Initial test: Non-contrast CT face/orbits Best for bony detail and muscle entrapment Look for: Orbital floor defect Herniation of orbital fat or inferior rectus Soft tissue entrapment Air-fluid levels in sinus (orbital floor = maxillary sinus) 💊 Management Step Details Avoid nose blowing Prevent orbital emphysema Oral antibiotics (sometimes) If sinus communication suspected (e.g. augmentin) Ice packs, head elevation Reduce swelling Surgical repair If: Entrapment Significant enophthalmos Persistent diplopia Large fracture (>50% of floor) | | Ophtho or ENT consult | Especially for entrapment or vision loss | 🔑 Board Clues & Must-Know Diplopia + upward gaze restriction = inferior rectus entrapment Bradycardia with eye movement = oculocardiac reflex CT = gold standard Don’t blow nose = prevent orbital emphysema

Answer 2

Dx: -!CT facial bones no contrast = gold standard -CT indicated if bony tenderness, step off, crepitus, entrapment -PE- acuity, fields, IOP, slit lamp, EOM -ophthalmology consult for dec acuity, widen intracanthal space (fx), orbital comartment syndrome (rock hard eyelids), CSF, entrapment esp if causing oculocardiac reflex -r/o brain bleed, c-spine fx, CSF leak, entrapment syndrome, airway Tx: - ABCs, trauma eval - DO NOT BLOW NOSE -elevated HOB -ice pack for first 48hrs for periorbital edema -nasal decongestants, corticosteroids -complications -> surgery -do NOT blow nose Call ophthalmology for any concerning findings such as: * Globe injury * ↓ visual acuity * Widened intercanthal space * Orbital compartment syndrome (rock hard eyelids) * CSF leakage * Entrapment esp if causing oculocardiac reflex

Answer 3

Nasal Congestion: sx not dx - stuffy nose - postnasal drip and rhinorrhea Sinusitis: -purulent discharge - FEVER if bacterial -facial pain and tender sinuses - often followes viral URI ->10 days - mucosa = erythematous - supportive tx and abx if bacterial Allergic rhinitis: -clear watery discharge - hx of allergies -itchy -PALE, boggy mucosa - sneezing - tx: antihistamines

Answer 4

Nasal Polyps: “Pale, non-tender, MOBILE, bilateral masses”, associated with asthma, aspirin allergy, chronic congestion, decreased smell Septal Hematoma: “Soft, FLUCTUANT swelling after nasal trauma on the SEPTAL SIDE”, anterior septum, painful, red/purple mass -worst morbidity of nose -complications: abscess, necrosis, saddle nose, perforation - blood between the perichondrium and cartilage - tx: I&D with bilateral packing (no internal packing); augmentin, ENT for removal in 2-3 days ## Footnote 🧊 Nasal Polyps “Pale, non-tender, MOBILE, bilateral masses” Arise from chronic mucosal inflammation Associated with: Asthma Aspirin allergy (Samter’s triad) Chronic congestion Anosmia / ↓ smell Usually benign, slow-growing Tx: Intranasal steroids, allergy control, ENT referral (surgical removal if obstructive or recurrent) 🩸 Septal Hematoma “Soft, fluctuant swelling after nasal trauma on the septal side” Red or purple, painful, obstructive Blood collects between the perichondrium and cartilage Location: Anterior nasal septum, can be unilateral or bilateral Urgency: ENT emergency — risk of: Abscess Cartilage necrosis Septal perforation Saddle nose deformity (worst nasal morbidity) ⚠️ Management Urgent I&D (do not pack internally) Bilateral external packing Augmentin (or other sinus-coverage abx) ENT follow-up for drain removal in 2–3 days

Answer 5

-acute breakdown and necrosis of MUSCLE Causes: -TRAUMA/COMPRESSION -Prolonged immobilization -Seizures -Burns -Compartment syndrome -meds (STATINs MC), substance abuse (amphetamines), infections (influenza), metabolic or genetic factors sx: -triad- muscle pain, weakness, dark urine (WINE COLORED URINE) -non-specific sx- fever, malaise, n/v, tachy, abd pain, oliguria Dx: -LABS: -↑ CPK (>20,000) !!! -↑ LDH -!Hyperkalemia, phos -Hypocalcemia -+/- AKI -U/A: MYOGLOBINURIA !!!! -Red/Brown/Pink/Dark urine that is heme (+) but no RBCs on microscopy!!!!! -EKG: +/- hyperkalemia if severe (peaked T waves) Tx: -IVF to flush out myoglobin -Treat any hyperkalemia!! -Severe -> dialysis -Complications: -ACUTE KIDNEY INJURY and ATN due to excess myoglobin ## Footnote 🧠 Definition Acute breakdown and necrosis of skeletal muscle → release of myoglobin, CK, electrolytes into circulation ⚠️ Common Causes Traumatic Non-Traumatic Crush injury / compartment syndrome Prolonged immobilization (overdose, post-ictal) Burns, electrical injury Seizures, extreme exertion Medications: statins (MC), fibrates, antipsychotics Substances: cocaine, amphetamines Infections: influenza, HIV, sepsis Metabolic/genetic: heat stroke, inherited myopathies 😖 Symptoms / Presentation Classic Triad (in <10% of cases!): Muscle pain Muscle weakness Dark urine ("wine-colored urine") Other signs: fever, nausea, vomiting, tachycardia, abdominal pain, oliguria 🧪 Diagnosis 🩸 Labs ↑ Creatine kinase (CK/CPK): often >20,000 U/L ↑ LDH ↑ Potassium, ↑ phosphate, ↓ calcium Metabolic acidosis +/- ↑ Creatinine (if AKI develops) 🚽 Urinalysis Myoglobinuria Urine heme (+) on dipstick No RBCs on microscopy = classic clue! 🫀 ECG Check for hyperkalemia: peaked T waves, widened QRS, sine waves 💧 Treatment Goal Action Prevent AKI Aggressive IV fluids (NS @ 200–300 mL/hr) Manage hyperkalemia Calcium gluconate, insulin + glucose, albuterol, bicarb Correct electrolytes Monitor K+, Ca2+, Phos Avoid nephrotoxins Stop statins, avoid NSAIDs Dialysis If severe AKI, persistent hyperK+ or acidosis ⚠️ Complications Acute Kidney Injury (AKI) → due to myoglobin-induced acute tubular necrosis (ATN) Electrolyte abnormalities → esp. hyperkalemia → arrhythmias Compartment syndrome DIC (rare) 🧠 Clinical Pearl: Heme-positive urine with no RBCs + CK >20,000 = Rhabdomyolysis

Answer 6

-CRITICAL reduction in blood flow to tissue epidemiology: -MC in lower limbs -MC = long bone fx -> tibia * - CRUSH INJURIES * - HIGH ENERGY TRAUMA* -Circumferential thermal burns -Tight casts -RF: Bleeding disorders or anticoagulation -OPEN fx can get compartment syndrome -CAN occur in low-energy or atraumatic injuries (drug overdose) Late or missed presentation: -Myonecrosis, Rhabdo, Contracture, Sensory loss, Infection, Non-union, Amputation, Death Sx: - LOSS OF TWO POINT DISCRIMIATION = earliest PE finding -Pain out of proportion -> 1st and most reliable finding -presents within hrs or within 48hrs of insult -Unrelieved with initial measures -!!Worse with passive stretching -Paresthesia's -!!Tense compartments: document in serial exams if tense vs soft -Not usually swollen -6 P’s as it progresses Dx: -Perform and document serial exams (q 30 mins) -Absolute compartment pressure > 30 mmHg or -Delta pressure < 30 mm Hg (delta = diastolic BP – compartment pressure) Tx: -Early recognition -!!Consult ortho, trauma, or acute care surgery for emergency surgical fasciotomy -Prior to surgery: -Remove all dressings / splints / casts** -Keep limb at neutral level -High flow oxygen -Improve BP with IVF -Give opioid analgesics! -incisions left open to recheck in 24-48hrs -> assess need for debridement -Monitor for rhabdo and renal injury

Answer 7

hard signs: need SURGERY -> OR - ABSENT PULSES - BRUIT or thrill - active/pulsatile hemorrhage - signs of limb ischemia - compartment syndrome - pulsatile or expanding hematoma soft signs: need ABI (<0.9) -> CTA -> OR - close proximity to vascular structures - major single nerve deficit - nonexpanding hematoma - reduced pulse - hypotension - posterior knee or anterior elbow dislocation

Answer 8

* Axial load injuries to the lower extremity can occur due to falling directly onto your feet (jump from a tall height) * Always suspect calcaneus fractures in patients with axial loading injuries to the lower extremities. If a calcaneus injury is found, or if patient is complaining of pain/neuro symptoms elsewhere after an axial load injury, look for concomitant fractures of the ankle and vertebrae. * Patients with calcaneal fractures will always be nonweightbearing on ED discharge * Watch out for compartment syndrome of the foot which occurs in 10% of calcaneal fractures and results in significant morbidity * Axial load injuires can occur to the head. This can be when something drops directly on the head, during contact sports, or during diving accidents in shallow water (extremely rare). * This can lead to fractures and dislocations of the vertebrae, spinal cord damage (cord syndromes), and even death. * Axial load injuries to the upper extremity are rare. As with all axial load, consider damage done much further up and away from the point of contact. ## Footnote 💥 Axial Load Injuries — High-Yield Review 📌 Definition Injuries caused by a vertical compression force transmitted through the body Think: fall from height, diving injury, blunt trauma directly onto head, spine, or feet 🧠 Mechanism Examples Fall from height → land on feet or butt Diving into shallow water → head/neck impact High-energy trauma to crown of head or spine Contact sports → head-first tackles 🦴 Common Injury Sites & Findings Injury Location Injury Pattern Feet Calcaneal fracture (↓ height, axial force) Spine Cervical spine fracture (e.g., Jefferson fracture = C1 burst) Thoracolumbar burst/compression fracture Knees Tibial plateau fracture (from axial loading of femur on tibia) 🚑 Red Flag Associations Spine injury + neuro findings: Spinal cord injury Central cord syndrome: UE > LE weakness, sensory loss, urinary retention Neurogenic shock (T6 or above): ↓ sympathetic tone → bradycardia + hypotension 👣 Calcaneal Fracture Specifics Always non-weight bearing on discharge Suspect with heel pain + fall from height Frequently associated with: Lumbar compression fractures Ankle injuries Watch for foot compartment syndrome (~10%) → requires urgent fasciotomy 🧪 Diagnosis X-rays: Calcaneus, spine, tibial plateau CT: Often needed for: Spine (burst or complex fx) Calcaneus (for fracture characterization) ⚠️ Clinical Pearl If you see a calcaneus fracture, always image the spine. And vice versa — spine fx + fall → image the feet.

trauma Flashcards

(32 cards)